Survey research was used to explore the beliefs of 963 staff
members regarding the myths to treating tobacco dependence and the
integration of tobacco dependence into substance abuse treatment
programs. The staff represented a mixture of residential, outpatient,
and prevention-based gender-specific (women only) treatment centers
throughout Ohio. The study found the following: a high percentage of
staff believed in the conventional myths associated with the treatment
of tobacco in chemically dependent persons; current smokers were
reluctant to support all substance abuse treatment facilities in
becoming tobacco-free, yet did support treating tobacco dependence in
their facilities; and former and never smokers supported tobacco-free
policies for their and all treatment facilities. Education and support
for staff in treating tobacco dependence is recommended.

**********

Tobacco use among chemically dependent persons is high with
prevalence rates estimated at 70-90% compared to 21% in the current
adult population in the United States (Batel, Pessione, Maitre, &
Reuff, 1995; Centers for Disease Control and Prevention [CDC], 2007;
Kalman, Morissete, & George, 2005; Richter, Ahluwalia, Mosier,
Nazir, & Ahluwalia, 2002; Sharp, Schwartz, Nigthingale, & Novak,
2003). Despite such a high percentage of tobacco users among chemically
dependent persons, substance abuse programs are slow to integrate
tobacco dependence into existing treatment services (Fuller et al.,
2007; Ziedonis, Guydish, Williams, Steinberg, & Foulds, 2006). This
reluctance is often fueled by prevailing myths concerning concurrent
treatment of alcohol, tobacco and other drugs as detrimental to
treatment outcomes (Gulliver, Kamholz, & Helstrom, 2006). Substance
abuse treatment staff are estimated to use tobacco at rates of 30-40%
(Bemstein & Stoduto, 1999; Friend & Levy, 2004; Fuller et al.,
2007). Staff resistance to the integration of tobacco into existing
treatment services may be rooted in myth and dogma as well as in its own
tobacco use. Substance abuse treatment facilities must address these
underlying issues in order to gain staff support and cooperation for the
integration and treatment of tobacco dependence. This study explores
staff: (a) beliefs about existing myths around treating tobacco
dependence; and (b) beliefs toward integrating tobacco dependence into
its substance abuse treatment programs.

LITERATURE REVIEW

Treating Tobacco Dependence: Prevailing Myths

Treatment for tobacco is often ignored or omitted within the
standard substance abuse treatment model, which is fueled by several
myths designed to discredit the needs for and benefits of addressing
this addiction (Fuller et al., 2007; Ziedonis et al., 2006). The
prevailing myths commonly discussed include the following: (a)
Chemically dependent clients do not want to quit using tobacco (Kalman,
1998; Kodl, Fu, & Joseph, 2006); (b) concurrent treatment will bring
detrimental consequences to recovery outcomes (Bowman & Walsh, 2003;
Joseph, Willenbring, Nugent, & Nelson, 2004; Kalman, 1998); (c)
tobacco is more benign than other substances (Gulliver et al., 2006);
and (d) addressing tobacco dependence would be too stressful for the
client (Ziedonis et al., 2006). Studies on the treatment of tobacco
dependence refute such myths and create stronger evidence for the
treatment of tobacco dependence with chemically dependent individuals.

Numerous studies have found that clients receiving substance abuse
treatment desire to quit using tobacco and are interested in receiving
treatment for their tobacco dependence either during or after substance
abuse treatment (Bernstein & Stoduto, 1999; Bobo, Lando, Walker,
& McIlvain, 1996; Burling, Burling, & Latini, 2001; Clarke,
Stein, McGarry, & Gogineni, 2001; Ellingstad, Sobell, Sobell,
Cleland, & Agrawal, 1999; Joseph, Lexau, Willenbring, Nugent, &
Nelson, 2004; Zullino, Besson, & Schnyder, 2000). Bernstein &
Studuto (1999) found that when implementing an optional educational
smoking program at an abstinence-based addiction treatment center, 55.6%
of staff and 38% of clients who smoked agreed to participate, and 17.5%
of clients were abstinent at the 12-month follow-up. Bobo et al. (1996)
found that 27.7% of recovering alcoholics made a serious quit attempt
within six months of discharge and Kohn, Tsoh and Weisner (2003) found
that 13% of smokers in a substance abuse treatment program quit using
tobacco when assessed at a 12-month follow-up study without receiving
formal tobacco dependence treatment. These studies refute this myth and
demonstrate that many tobacco dependent clients would like to quit using
tobacco and do make serious quit attempts on their own.

Treating chemically dependent individuals concurrently for tobacco
dependence is often believed to interfere with recovery outcomes; yet
research has continually found that failure to quit smoking may lead to
worse treatment outcomes and may actually jeopardize sobriety (Bobo,
McIlvain, Lando, Walker, & Leed-Kelly, 1998; Frosch, Shoptaw, Nahom,
& Jarvik, 2000; Hurt, Eberman, & Croghan, 1994; Joseph,
Willenbring et al., 2004; Kohn et al., 2003; Lemon, Friedman, &
Stein, 2002; Toneatoo, Sobell, & Sobell, 1995). Kohn et al. (2003)
found that, at a 12-month follow-up, 69.8% of men and women who quit
using tobacco while in substance abuse treatment and 62.9% of nonsmokers
were significantly (pThe belief that tobacco is a more benign substance versus other
drugs of addiction is based on arguments that overlook social and health
consequences. In actuality, tobacco use is the leading cause of
preventable death in the United States and causes more deaths than
alcohol, cocaine, crack, heroin, homicide, suicide, human
immunodeficiency virus (HIV) and motor vehicle accidents combined (CDC,
2007; U.S. Department of Health and Human Services [HHS], 2006).
Although the short term effects of non-tobacco chemicals appear more
dangerous (Gulliver et al., 2006), chemically dependent individuals are
more likely to die from tobacco-related diseases than from the use of
non-tobacco chemicals (Hurt, Eberman, Slade & Karan, 1993; Hurt et
al., 1996). Non-tobacco chemicals do pose threats to the health of
substance abuse treatment clients, yet tobacco appears to exacerbate
these threats and is more likely to harm the client with continued use
(York & Hirsch, 1995). Bein and Burge (1990) note the synergistic
effect of tobacco and other drug uses are estimated to be 50% greater
than either used alone, further complicating the physical health
consequences of poly-substance use. Prochaska et al. (2004) highlight
the power of the implicit message found in the exclusion of tobacco from
treatment: quitting tobacco is "not a priority for recovery or
health" (p. 1154). Therefore, when considering the health of the
client, tobacco is a drug that should not be ignored.

Concurrent treatment for alcohol, tobacco and other drugs is
perceived as too stressful for clients (Rohsenow, Colby, Martin, &
Monti, 2005; Ziedonis et al., 2006); therefore, clients are often
encouraged to tackle their tobacco addiction at a later time. This
approach to tobacco dependence is counter to what is often expressed in
abstinent-based substance abuse treatment programs where clients are
required to "quit all drugs at one time." For example,
individuals addicted to cocaine are not permitted to use marijuana or
alcohol while receiving treatment or encouraged to use these substances
once they leave treatment. A menu-like approach to addiction where one
may pick-and-choose which drugs he or she would like to abstain from is
generally not taken, except in the case of tobacco. Therefore, excluding
tobacco from this list of restricted chemicals is contradictory to the
overall message of abstinence. As was noted above, concurrent treatment
for tobacco and other drugs is not detrimental (Reid et al., 2008) and
has been found to improve treatment outcomes and increase sobriety rates
post treatment (Frosch et al., 2000; Kohn et al., 2003; Lemon et al.,
2002; Prochaska et al., 2004). The evidence suggests that not including
tobacco dependence in treatment could actually cause more stress to the
client by acting as a trigger for other substances (Williams et al.,
2005; Ziedonis et al., 2006).

Treating Tobacco Dependence." Staff Influence

Staff members play a crucial role in the recovery process for
persons in substance abuse treatment and their attitudes and actions
will influence the treatment of tobacco dependence. Acknowledgement of
the deleterious nature of tobacco and the addictive properties
associated with its use are the first steps toward integration in
substance abuse treatment. Gaining the support of all staff members may
prove difficult as their own addictions to tobacco may cloud their
opinions on the treatment of tobacco dependence. Further, when the
existing culture is tailored to the needs of smoking clients including
smoke breaks, budgeting for tobacco purchases or tobacco as a treatment
reward, staff may view the task of treating tobacco as too daunting.
These factors surrounding tobacco offer it a protected status in many
substance abuse treatment facilities.

Substance abuse treatment staff members are often reluctant to talk
with clients about tobacco cessation (Friend & Levy, 2004), and
those members who smoke are more likely to be resistant to the treatment
of clients for tobacco dependence (Bobo, Slade, & Hoffman, 1995;
Fuller et al., 2007; Hahn, Warnick & Plemmons, 1999). Approximately
30-40% of substance abuse treatment staff use tobacco (Bernstein &
Stoduto, 1999) and these staff members are least likely to encourage
chemically dependent clients from quitting (Ziedonis et al., 2006). In
order to move the substance abuse treatment field toward the integration
of tobacco dependence into existing treatment programs, the beliefs of
staff in regard to treating tobacco should be assessed as well as their
beliefs in the myths against treating tobacco. Assessing the beliefs of
staff can help identify gaps in support for the treatment for tobacco
dependence and can provide the baseline for staff education on this
protected addiction.

This survey research study explored the beliefs of staff regarding
the integration of tobacco dependence into substance abuse treatment
programs and the myths regarding tobacco dependence treatment.
Additionally, this study assessed the readiness of tobacco-dependent
staff members to address their own addictions.

METHODS

This study was administered by the Ohio Women's Coalition
Smoking Cessation and Prevention Initiative (OWCSC&PI), which was
funded by the Ohio Tobacco Prevention Foundation (OTPF). The
OWCSC&PI was administered by Amethyst, Inc, a gender-specific (women
only) treatment center in Columbus, Ohio, and served to provide training
and technical assistance to organizations interested in treating
tobacco. Although the OWCSC&PI worked primarily with gender-specific
substance abuse treatment programs, the program provided services to
mental health treatment facilities, health care and educational
organizations. The OWCSC&PI conducted this study in order to better
align its training initiatives with the needs of the targeted
gender-specific treatment facilities.

This descriptive study consisted of survey research in which a
21-item questionnaire was sent to the 73 certified gender-specific
substance abuse treatment facilities in Ohio. The survey instructions
asked for distribution to staff members including members of management,
direct service staff, and non-direct service staff. The completion of
the questionnaire was voluntary and was strictly confidential. An
initial questionnaire, and a follow-up questionnaire to those who had
not responded initially, yielded a total of 994 questionnaires from 54
substance abuse treatment facilities; 2 agencies had incorporated
tobacco-free policies at the agency and were therefore not included in
the analysis leaving 963 questionnaires from 52 substance abuse
treatment facilities.

The questionnaire was developed by the OWCSC&PI staff and
consisted of demographic information (age, gender), opinion questions
and knowledge assessment of tobacco dependence. Current and never
smokers were determined by the questions, "Do you currently use
tobacco product?" (yes or no). Information on use and cessation
history was gathered including age of onset, quit attempts, length of
abstinence, and methods utilized for quitting. Questions on amount of
type of tobacco use were not in this survey. Persons who answered
"no" to being a current smoker, because they either never used
or formerly used, provided detail on their quit history indicating how
long the former users had remained abstinent.

A question that mirrored the Stages of Change was used in order to
assess the readiness of staff to address its own addiction (Prochaska
& DiClemente, 1984; Prochaska, DiClemente, & Norcross, 1992).
The Stages of Change is an element of the Transtheoretical Model (TTM)
that assesses an individual's readiness to make a behavioral change
and theorizes that individuals tend to move, not necessarily in a linear
fashion, through five stages: precontemplation, contemplation,
preparation, action, maintenance. Current stage of change was assessed
by asking smokers and former smokers "do you want to quit using
tobacco?" and were given the following possible responses: (a) I am
not considering quitting in the next six months (precontemplation); (b)
I am considering quitting within the next six months (contemplation);
(c) I am planning to quit within the next thirty days (preparation); (d)
I have quit within the past six months (action); and (e) I have not
smoked within the past six months (maintenance) (Prochaska et al.,
1992).

Opinion and knowledge assessment questions were based on
conventional beliefs and myths about tobacco use and cessation for
chemically dependent persons as demonstrated through the research listed
in the literature review. The staff members' opinions toward
treating tobacco dependence were assessed by asking staff to respond
either agree, disagree, or no opinion to the following statements: (a)
All alcohol and other drug (AOD) treatment facilities should be
tobacco-free; (b) I think this agency should treat nicotine dependence;
and (c) I think this agency should be tobacco-free. The staff
members' beliefs in the myths towards treating tobacco dependence
were assessed by asking the staff to respond either agree, disagree, or
no opinion to the following statements: (a) Recovering
alcoholics/addicts can quit smoking without endangering their sobriety;
(b) quitting smoking would interfere with recovery from other drugs; (c)
stopping tobacco use adds unnecessary stress to individuals in the midst
of treatment; (d) a successful tobacco cessation program requires that
staff be tobacco-free; and (e) there is evidence that stopping tobacco
use enhances alcohol and drug abstinence rates.

Data Analysis

Crosstabulations were employed to determine the percentage of
current, former and never smokers in regard to age and gender, and to
determine the percentage of current and former smokers in regard to age
at smoking initiation, number of past quit attempts, length of
abstinence, and methods used to quit smoking. Chi-square tests of
independence were conducted to determine any significant differences
between the characteristics across the three groups (current, former and
never smokers) with statistical significance set at a .05 level.
Crosstabulations were employed to determine the frequencies and
percentages of current, former, and never smokers that responded either
agree, disagree or no opinion to the questions addressing staff
members' beliefs towards treating tobacco dependence; and
chi-square tests of independence were performed to examine the
relationship between smoking status (current, former, and never smokers)
and level of agreement to the statements (agree, disagree, or no
opinion). Statistical significance was set at a .05 level.

RESULTS

In regard to the agencies that were represented in this study, 50%
were outpatient, 36.5% were residential, and 13.5% were prevention. The
19 agencies that did not respond consisted of 42.1% from residential,
36.8% from outpatient, and 21.1% from prevention. Over 20% of the
respondents were male (N= 152) and 79.8% were female (N=601). Over 26%
identified as a current smoker (N=250), 48.7% as a former smoker
(N=465), and 25.1% as a nonsmoker (N=240). For stage of change, 35.9% of
current smokers reported being in the precontemplation stage, 43.3% in
the contemplation stage, 18.0% in the preparation stage, and 2.4% in the
action stage. Table 1 reveals the characteristics by current smokers,
former smokers, and never smokers. Nearly 60% of current smokers and
64.4% of former smokers reported having made between 1-3 quit attempts,
and 24.9% of current smokers and 93.4% of former smokers reported having
a length of abstinence that was greater than one year. The most common
method used to quit smoking was "just quit" for current
smokers (42.5%) and former smokers (61.3%) with only 13.6% of smokers
and 5.5% of former smokers using Nicotine Replacement Therapy (NRT) to
assist with their quit attempt.

Table 2 reports the frequencies and percentages of level of
agreement of current smokers, former smokers, and never smokers for each
statement. The majority of current, former and never smokers agreed that
recovering alcoholics/addicts can quit smoking without endangering their
sobriety, and disagreed that quitting smoking would interfere with
recovery from other drugs. There were no statistical differences among
the groups. The majority of never smokers disagreed that stopping
tobacco use adds unnecessary stress; yet the majority of current smokers
and former smokers agreed ([chi square] (4, N = 923) = 47.81, pIn regard to attitudes towards treating tobacco dependence, the
majority of current smokers disagreed that all AOD treatment facilities
should be tobacco-free compared to the majority of former smokers and
never smokers who agreed ([chi square] (4, N = 919) = 1.35E2, pDISCUSSION

This study has explored substance-abuse treatment staffs'
beliefs in the prevailing myths about treating tobacco dependence in
substance abuse treatment centers (Bowman & Walsh, 2003; Gulliver et
al., 2006; Joseph, Willenbring et al., 2004; Kalman, 1998; Kodl et al.,
2006; Ziedonis et al., 2006). The results of this study show a mixture
in beliefs about the treatment of tobacco dependence, particularly by
smoking status, and point to either a lack of knowledge or acceptance
for treating tobacco dependence from some staff members as it relates to
overall sobriety from alcohol and other drugs. The findings indicate a
need for staff education on the synergistic effects of poly-substance
use, which includes tobacco. Staff education administered at the agency
or system level should provide a review of the evidence supporting the
treatment of tobacco dependence concurrently with treatment for other
substances (Ziedonis, et al., 2006).

The current smoking status of staff and level of staff support are
two critical factors to consider when moving towards incorporating
tobacco dependence into treatment or a tobacco-free policy in an
organization. The support of all staff is often necessary for a
treatment program to be successful so that the message for treatment of
tobacco is consistent (Fuller et al., 2007; Ziedonis et al., 2006). This
study found that 26.2% of staff members were current smokers, 48.7% were
former smokers and 25.1% were nonsmokers, which supports prior research
indicating that staff members of substance abuse treatment programs
smoke at a higher rate compared to the adult population (Bobo et al.,
1995; Friend & Levy, 2004; Fuller et al., 2007). With over a quarter
of staff members claiming to use tobacco, treatment facilities must
engage these staff members as they will have to address their own
tobacco use while simultaneously assisting clients.

The majority of current tobacco users in this study considered
themselves in the contemplation or preparation stage indicating their
readiness to address their tobacco use and make a quit attempt within
six months or less. Treatment facilities can provide extra support to
these smoking staff members through a variety of emotional, social and
monetary means, such as assisting with the payment for individual or
group counseling, nicotine replacement therapy (NRT), hypnotherapy or
other treatments. Educational activities, smoke-out days or work-based
support sessions, and tobacco cessation groups provide a means to foster
discussion and encourage persons in their quit processes.

Treatment facilities may encounter reluctance from current smokers
to treating tobacco dependence or supporting tobacco-free policies due
to their own tobacco use. Although the findings from this study revealed
that the largest percentage of current, former and never smokers agreed
that their agencies should treat tobacco dependence, the majority of
current smokers were reluctant to move their agencies and all substance
abuse programs towards incorporating tobacco-free policies. Treating
tobacco dependence enables clients to receive treatment; yet an
agency-wide tobacco-free policy would require the smoking staff to
address its own tobacco use likely through the incorporation of tobacco
into a drug-free workplace policy. Alternatively, the majority of former
smokers and nonsmokers were supportive of incorporating a tobacco-free
policy at their agency. These results further demonstrate the necessity
for staff training on the evidence supporting treating tobacco
dependence and on addressing current smoking staff members' own
concerns and fears about treating their tobacco use through emotional,
social or monetary measures.

The findings of this study should be interpreted against several
limitations. First, the questionnaires provide data that are based on
staff self-report and the answers cannot be verified. Second, this study
had to incorporate a convenience sample as the current data from the
state do not indicate the number of persons employed throughout
Ohio's publicly-funded treatment system leaving the number of
non-respondents unknown. Last, the results from this study represent the
staff members from abstinence-based, gender-specific substance abuse
treatment facilities across Ohio, as this was the target population for
the OWCSC&PI. Future research should be conducted with staff members
of other types of treatment facilities to determine any differences in
staff members' beliefs towards treating tobacco dependence. Despite
the limitations, this study provides further insight into the beliefs
and attitudes of staff from substance abuse treatment facilities.

This study has reviewed the evidence supporting the treating of
tobacco dependence concurrently with other chemical dependencies and the
influence of staff members on treating tobacco dependence. The findings
from this study highlight a continued belief in myths surrounding
treating tobacco dependence, particularly by current smokers, reluctance
for all substance abuse facilities to move towards a tobacco-free
policy, yet a general support for treating tobacco dependence within
their facilities. In order to move forward with the treatment of tobacco
dependence in substance abuse treatment, facilities must educate staff
to the evidence supporting this treatment and support staff members who
are reluctant to make the change, particularly as it influences their
tobacco use.

The authors confirm that this manuscript has not been submitted
simultaneously to any other journal.

Prepared under Grant number 03-0076 from the Ohio Tobacco
Prevention Foundation (OTPF) granted to Amethyst, Inc. Points of view or
opinions in this document are those of the authors and do not
necessarily represent the official position of the Ohio Tobacco
Prevention Foundation.

An earlier version of this paper was presented as a poster at the
World Conference on Tobacco OR Health, Washington, DC, USA, July, 2006.

U.S. Department of Health and Human Services. (2006). The health
consequences of involuntary exposure to tobacco smoke: A report of the
Surgeon General. U.S. Department of Health and Human Services, Centers
for Diseases Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health.